Consciousness, power and drug effects
Scientists no longer believe that a drug has a simple physiological action, essentially the same in all humans. Experimental, anthropological, and sociological evidence has convinced most observers that drug effects vary greatly, depending on variations in the physiology and psychology of the persons taking them, on the state the person is in when he ingests the drug, and on the social situation in which drug ingestion occurs. We can understand the social context of drug experiences better by showing how their character depends on the amount and kind of knowledge available to the person taking the drug. Since distribution of knowledge is a function of the social organization of the groups in which drugs are used, drug experiences vary with variations in social organization. I will explore that possibility in three quite different settings of drug use: the illegal use of drugs for pleasure, the use of medically prescribed drugs by doctors' patients, and the involuntary ingestion of drugs by victims of chemical warfare.
Drug effects have a protean character, varying from person to person and place to place. They can vary in that fashion because drugs almost always have more than one effect on the organism. People may conventionally focus on and recognize only one or a few of these effects, and ignore all others as irrelevant. Most people think the effect of aspirin is to control pain; some know that it also reduces fever; few think of gastric irritation as a typical effect, though it is. The example suggests that users focus on "beneficial" effects and ignore those irrelevant to the benefit they seek. Because drugs have so many effects, the effects can be interpreted variously and thus reflect extremely subtle contextual influences.
Drug Effects, Knowledge, and Social Structure
When a person ingests a drug, his subsequent experience is influenced by his ideas and beliefs about that drug (Becker 1967).
What he knows about the drug influences the way he uses it, the way he interprets its manifold effects and responds to them, and the way he deals with the sequelae of the experience. Conversely, what he does not know affects his experience too, making certain interpretations impossible, as well as actions based on that missing knowledge. I use "knowledge" in an extended sense to refer to any ideas or beliefs about the drug that any of the actors in the drug use network (e.g., illicit drug sellers, physicians, researchers, or lay drug users) believe have been tested against experience and thus carry more warrant than mere assertions of faith. All people are probably likely to take knowledge they believe to have been tested against experience as a guide to their own interpretations and actions. Members of contemporary Western societies, who accept the value of science and scientific knowledge so uncritically, must do so doubly.
Dosage. Many drug effects are dose-related. The drug has one set of effects if you take x amount and quite different effects if you take 5x. Similarly, drugs have different effects when taken orally, by inhalation, intramuscularly, or intravenously. How much of the drug you take and how you take it depend on what you understand to be the proper amount and route of use. Those understandings depend on what you have learned from sources you consider knowledgeable and trustworthy.
If I have a headache and ask how many aspirin I should take, almost anyone will tell me two; that knowledge is widely available both on the package and in lay medical folklore. It will also be understood that I should swallow the aspirin rather than dissolving them in water and injecting them. Most people, however, have no knowledge readily available about the use of a large variety of drugs, either those medically prescribed (e.g., cortisone) or those used without benefit of medical advice (e.g., LSD). To use them, would-be users develop some notions about how much to take and how to take it, either by trial-and-error experimentation or by adopting the ideas suggested by sources they consider reliable (scientists, physicians, or more experienced drug users). Those sources usually have recommendations about drug use. They can tell the prospective user how much he should take and how he should take it in order to cure his cold, control his blood clotting time, have a mystical experience, get high, or whatever other effect he may desire. They can also tell him how much will be too much, producing unwanted effects of overdose. They may tell him to take four pills of the kind the druggist will sell him, one after each meal and one before retiring; they may give more elaborate instructions, such as those given diabetics about controlling their metabolic balance with food and insulin; they may informally suggest that the novice has probably smoked enough hashish and ought to stop until it takes effect; or tell him that most people find five hundred micrograms of "good acid" enough to induce an adequate amount of consciousness expansion.
Using these acquired understandings, the user takes an amount whose effect he can more or less accurately predict. He usually finds his prediction confirmed, though the accuracy of conventional knowledge (as opposed to its confirmation by a retrospective ad)ustment of expectations) needs to be known. In this way, his access to knowledge exerts a direct influence on his experience, allowing him to control the physiological input to that experience.
This analysis supposes that the user has complete control over the amount he takes, any variation being due to variations in his understanding of the consequences of taking different doses or taking the drug in different ways. But drug availability is often regulated by law, so that the user can take only what he can get under given conditions of supply. I might want to take large amounts of cortisone, but am restricted to what a doctor will prescribe and a pharmacist will sell. Except in hospitals, doctors ordinarily prescribe and pharmacists sell amounts larger than recommended for one-time use, so that a user can take more than he is "supposed to," as sometimes occurs with prescriptions for barbiturates. I can also purchase drugs illicitly or semi-licitly (e.g., from a friendly neighborhood pharmacist) and so evade medical control of dosage.
A user also loses control over the amount he takes when someone more powerful than him forces him to take more than he wants or, indeed, to take a drug he does not want to take at all. This occurs commonly in pediatric medicine, in mental hospitals, and in tuberculosis hospitals when patients are given drugs whose taste or effects they dislike; in chemical and biological warfare; and in the addition of chlorine or fluorides to city water supplies. In these cases, the relevant knowledge for an understanding of the drug's effects, insofar as they depend on dosage, is the knowledge held by the powerful person or organization which can force the user to ingest the drug.
Main effects. Social scientists have shown how the definitions drug users apply to their experience affect that experience. Persons suffering opiate withdrawal will respond as "typical" addicts if they interpret their distress as opiate withdrawal, but not if they blame the pain on some other cause (e.g., recovery from surgery). Marijuana users must learn to interpret its subtle effects as being different from ordinary experience and as pleasurable before they "get high" (Becker 1953b). Indians and Caucasians interpret peyote experiences differently (Aberle 1966), and LSD "trips" have been experienced as consciousness expansion, transcendental religious experience, mock psychosis, or being high (Blum et al. 1964).
The user brings to bear, in interpreting his experience, knowledge and definitions derived from participation 'in particular social groups. Indian culture teaches those who acquire it a different view of the peyote experience than is available to non-Indians. Marijuana users learn to experience the drug's effects from more experienced users. LSD trips are interpreted according to the understandings available in the various settings in which it is taken.
The process has been studied largely in connection with nonmedical drug use, but presumably occurs in medical use also. Here the chief source of authoritative interpretations is the physician who prescribes the drug and, for many people, the pharmacist. Patients on maintenance regimes of a drug for a chronic disease like diabetes, epilepsy, or gout might develop a user's "drug culture," meeting in doctors' and hospital waiting rooms, or consulting the Internet, and trading information and generalizing from their common experiences, but this has not been extensively studied.
In both cases, the knowledge acquired from authoritative sources lets the user identify the drug's main effect, know when it is occurring, and thus decide that what is occurring, even when it seems undesirable or frightening, is really acceptable, if only because expected.
Side effects. Side effects are not a medically or pharmacologically distinct category of reactions to drugs. Rather, they are effects not desired by either the user or the person administering the drug. Both side effects and main effects are thus socially defined categories. What is a side effect or a main effect will vary according to the perspective applied; mental disorientation might be an unwanted side effect to a physician, but a desired main effect for an illicit drug user.
A drug user's knowledge, if adequate, lets him identify unwanted side effects and deal with them in a way satisfactory to him . A user concentrating on a desired main effect (relief from a headache) may not observe an unpleasant side effect (gastric irritation) or may not connect it with his use of aspirin. He interprets his experience most adequately if those who prepare him for the drug's main effects likewise teach him the likely side effects and how to deal with them. Illicit drug users typically teach novices the side effects to look out for, give reassurance about their seriousness, and instruction in how to avoid or overcome them; this mechanism probably prevents a great deal of potential pathology, though it can only operate when drug users are adequately connected in networks through which the information can pass. Many LSD users became expert at "talking down" people experiencing "bad trips," and marijuana users routinely teach novices what to do if they get "too high." Physicians probably vary in the degree to which they teach patients the potential side effects of the drugs they prescribe. Patients for whom physicians prescribe drugs seldom share a user culture. Since their medication may produce potent side effects, they can experience profound effects without knowing their prescribed drug is responsible, should the physician fall to inform them. The physician himsclf may not know, since the drug may have become available before the effects had been discovered; this seems to have happened when oral contraceptives were introduced and many women experienced edema, depression, vascular difficulties, and other undesired effects which no one, at the time, attributed to contraceptive pills (Seaman 1969).
Research and communication. Knowledge and the social channels through which it flows affect the interpretations and responses of a drug user to the experience the drug produces. Where does that knowledge come from? We can call its production "research," using the term in the extended way I have been speaking of knowledge. Research, so conceived, consists of the accumulation of ideas tested more or less systematically against experience of the empirical world. Researchers may use elaborate techniques and equipment or rely on simple devices and modes of analysis. At one extreme, the research pharmacologist systematically tests the effects of a drug on a wide variety of organ systems; at the other, a casual experimenter with a drug he thinks will get him high takes it over a period of weeks, noting his own reactions, and possibly comparing them with those of others experimenting with the same drug.
Research, especially that concerning subjective experiences produced by drugs, relies heavily on conventionally accepted rules of logic, inference, and common sense and scientific reasoning. Those rules help people decide when they have "experienced" something and what has produced the experience. Even when a variation from the ordinary that might be due to ingestion of a drug is identified, drug users often have to decide whether it is an ordinarily uncommon event or something special that might be due to the drug. Marijuana users, for instance, experience considerable hunger and must decide whether it is ordinary hunger or drug-induced. In deciding such questions, users make use of such commonsense notions as that antecedents produce consequences, lay versions of scientific procedures like Mill's method of difference.
This leads to the question of whether drug effects are entirely mental constructs or whether they are in some way constrained by physiological events in the body. To what degree can people have, as research on placebo effects suggests, "drug experiences" which have no physiological base? Experimental work (Schacter and Singer 1962) suggests that there must be some physiological basis for the experience. Without arguing the matter here, I believe that there must be some physiological event to be interpreted, but that it need not be drug-caused. Human beings experience a variety of physiological events all the time; when one is properly alerted, those ordinary events can be interpreted as drug-caused, as can events that in fact are drug-caused.
In any event, anyone who wishes to demonstrate to himself and others that he is experiencing a "drug effect" is constrained by the rules of common sense and folk or professional science. He cannot convince himself of the validity of his experience unless he can manipulate some actual experience according to those rules to produce an acceptable conclusion. (To the degree that other systems of producing knowledge are employed--e.g., divination--users appeal to their rules for validation.)
The kind of research done on a drug depends on the facilities, technical skills, and motivations available to those who do it. I describe varieties of social structures producing research later, so will not go into them here. Similarly, whatever knowledge has been accumulated may or may not be available to the ultimate user of the drug, depending on the constraints on communication in the organizations in which the drug use occurs.
We can distinguish three major social structures in which drug use occurs, according to the degree of control the ultimate users of the drug exercise over their own drug taking and especially over the production and distribution of drug-relevant knowledge. In one variety users retain control; the major empirical case is illicit drug use for pleasure, though the use of patent medicines provides an interesting comparison. In a second variety, the user delegates control to an agent presumed to act in his behalf; the major empirical case is modern medical practice, though the use of drugs for religious purposes is also relevant. Finally, in some cases, chemical warfare being the most prominent, the user has no control over his ingestion of the drug or over the production and distribution of knowledge associated with use of the drug.
In a situation of user control, such as the illicit use of drugs for pleasure, users takes as much as they want on whatever schedule they want; their dosage is self-initiated and self-regulated. They rely on knowledge generated in user groups to organize their drug-taking activities and interpret their drug experiences. They may feel substantial pressure from drug-using peers with whom they associate, but their use is voluntary and under their control in that no one has issued anything as authoritative as a medical order and no one has forced the drug on them over their objections, as occurs in chemical warfare and forced medication.
Users generate knowledge about the drugs that interest them largely by their own research, though that may include consulting such scientific and medical sources as pharmacology texts or the Pbysicians' Desk Reference, available in libraries or on-line. They use the lay research techniques available to them, largely self-experimentation and introspective observation. These methods are particularly appropriate when the effects to be investigated consist largely of subjective experiences difficult to tap by other means. While such methods are unreliable in individual cases, they are less likely to be influenced by idiosyncratic errors when a large number of users pool their observations and produce generalizations consonant with their collective experience. The reliability of generalizations so constructed depends on the efficiency of the conununication channels through which information moves and the adequacy of the mechanism for collating it.
Ordinarily, information about an illicitly used drug accumulates slowly, often over many years, in the pooled experience of users, who compare notes on their own experiences and those of others they have heard about. Insofar as users are socially connected, even though very indirectly, over a long time a large number of experiences circulate through the connected system and produce what can be called a "drug culture" (not the melange of political and cultural attitudes the term is often applied to, but rather a set of common understandings about the drug, its characteristics and the way it can best be used). The development of knowledge about marijuana probably best approximates this model, many years of extensive marijuana use in the United States having produced a vast body of lore which does not vary much by region or social group.
Other methods of cumulating and collating knowledge occasionally occur. The drug known as STP underwent a hip equivalent of the mass testing of polio vaccines when thousands of pills containing it were thrown from the stage at a Be-In in San Jose, California. Though no one knew what they were, many took them and within a few days most interested people had heard something about their effects. Information accumulated at the Haight-Ashbury Free Medical Clinic and other places where people suffering adverse reactions were likely to go. In a short time, the major effects, appropriate dosages, likely side effects and effective antidotes were well known.
Knowledge produced this way has certain defects. It cannot discover anything not capable of being discovered by the simple techniques known to a mass population of users. If, as was alleged, LSD damaged chromosomes and thus produced birth defects in offspring even after drug use ceases, typical styles of user research could not discover it, for that kind of knowledge requires more sophisticated equipment and techniques of analysis than users have available. Further, any unwanted effect whose onset is delayed is likely to be missed by user research, which relies on simple and immediate cause-effect relations; if the effect occurs a year after use begins, the user population may not discover the connection. (If, however, the user population includes well-trained scientists, as was always the case with LSD and is increasingly true with respect to all psychedelic drugs, this problem can be overcome.) Finally, the effectiveness of the research is limited by the connectedness of the user network. The operation depends on redundancy for the reliability of the knowledge produced, and poorly connected networks may gather insufficient data to overcome the unreliability of the individual datum. Uunderground news media might help with this difficulty; insofar as they are widely read, they can provide an otherwise nonexistent link between isolated users or user groups.
But knowledge produced by user research has the great virtue of being directed precisely to the questions users are interested in having answered. If they want to know whether the drug will make them high, the available research, conducted by people who share that interest, will provide an answer. In this it differs from research done for medical purposes, which is typically directed to questions raised by scientists or physicians, not by the ultimate user of the drug.
Users thus have available, under optimal conditions of knowledge production, relatively reliable and accurate answers to their questions about the drug they use. They use this knowledge to maximize the benefits they desire from use of the drug, whatever those benefits might be, and to minimize side effects. Often, because they participate in user groups, when a question arises whose answer they do not know, someone who does know it is readily available. This is particularly important in dealing with potentially dangerous or disturbing side effects. Naturally, the optimal circumstances seldom obtain; when knowledge is incomplete, inaccurate, or unavailable, users will have predictable troubles. This is particularly obvious when a drug first appears and relevant knowledge has not yet been produced and disseminated.
Another instance of user control--the use of patent medicines--shows the importance of the character of user networks. If my informal observations and speculations are correct, people produce knowledge about patent medicine effects either on their own or in small family groups. Consider laxatives. The constipation they are used for is presumably not widely discussed among people suffering from it. Users cannot easily identify one another as fellow sufferers and thus as potential sources of information. Parents may share the results of their own experiments with their children, as may spouses with one another, but one can imagine that the knowledge would not move much beyond that. Specialized groups (e.g., fellow inmates of an old people's home) might share such information, but in general, knowledge probably would not cumulate, except in families (perhaps descending, like toilet words, in the female line); each new user or small group would have to rediscover it. My speculations may be incorrect, but they highlight the importance of communication channels in understanding the experiences of users who control their own drug use.
Control by the User's Agent
When the user delegates control to an agent, interesting variations in the production and distribution of knowledge occur, with equally interesting variations in the kinds of experiences users have. The major empirical case is that of physicians prescribing medication for their patients (though an interesting variation is provided by religious use of drugs, as in the relation between Don Juan and his pupil Carlos Castaneda ). Here the user takes the drug the doctor prescribes for him, in the amounts and on the schedule the doctor recommends. The doctor's prescription reflects what the doctor wants to accomplish, rather than what the patient wants; their desires may coincide, but need not and in many cases do not.
Doctos use at least two criteria in evaluating drugs. They want to alleviate some dangerous or unpleasant condition the patient is suffering from, in a way clearly visible both to both parties. The drug effect which most interests the doctor is one which produces demonstrable (in the best case, visible to the patient's naked eye) improvement. But doctor also use a second criterion: they do not want the drug to interfere with their control over the patient. The rationale for that desire is well known: since (the rationale goes) the doctor knows what will help patients better than the patients themselves, patients must surrender themselves to the physician to achieve maximum results; if patients reject the physician's advice their health may be impaired. While I do not believe the rationale is factually correct, it is unnecessary to demonstrate that to observe that doctors believe they have a legitimate interest in maintaining what Eliot Freldson (1961, 1970a, 1970b) has usefully labeled "professional dominance."
Patients usually rely on physicians for their knowledge about dosage, main effects, and side effects of the drug prescribed. But physicians may not give patients all the knowledge available to thyem, because they do not want patients to use that knowledge as a basis for disobeying medical orders (Lennard et al. 1972). Henry Lennard gave me a telling example. Certain of the tranquilizing drugs sometimes produce an unusual effect on male sexual functioning; while the man experiences orgasm, no ejaculation occurs. This understasndably causes those who have the experience some anxiety. Since the drugs are given to relieve anxiety, Lennard asked psychiatrists why they did not tell patients that this might occur. "If I did that," ran the typical answer, "the patient might not take the drug and, in my judgment, he should run the risk of that anxiety in order to protect himself from his basic anxieties." Physicians also withhold information about side effects because suggestible patients often experience effects they have been told about, even when there is no physiological basis for the experience. They believe that this risk outweighs the risk of morbidity associated with lack of information, but I don't know if that has even been demonstrated.
Sometimes physicians do not give patients adequate information about the experience the drug will produce because they do not have the knowledge themselves. Research on drugs for medical use is organized quite differently from user research, and its organization creates substantial barriers to a free flow of information. Drug research is a highly specialized discipline, with its own journals, professional societies, and scientific world to which practicing physicians usually do not belong. They do not follow the latest developments in pharmacology, read its journals, or attend meetings of its scientific organizations. So they depend for their knowledge of drug effects on such general medical literature as they keep up with, on their immediate colleagues, and on the knowledge provided by pharmaceutical companies through their literature and salesmen (Coleman et al. 1966). Most of their knowledge, especially of new drugs, probably comes from the last source. Some physicians, especially those in specialized practices who see many cases of the same disease, may engage in casual experimentation similar to that done by illicit drug users, trying different dosages and treatments on different patients. They may then pool their observations with like-minded specialists and generate knowledge similar to that contained in drug-user cultures, with the same advantages and drawbacks.
Another serious barrier to practicing physicians' acquisition of knowledge about the drugs they prescribe arises from the organization of pharmaceutical research and manufacture. While pharmaceutical companies, the scientists who work for them, and the physicians who participate in their drug testing programs want to produce medically valuable drugs that will help combat disease, they are aIso interested, as many congressional investigations and investigative reporters have shown, in profits (Harris 1964). They design their research to produce profitably marketable products which can be sold, via physiclans' prescriptions, to the public, and which will also pass government tests of purity, efficacy, and lack of dangerous side effects. They look primarily for drugs which will produce (or seem to produce) effects on diseased patients, of the kind physicians want, or can be persuaded to want, to produce. They appear to investigate possible side effects only so far as required by prudence and the law. (We have no studies of the organization of pharmaceutical research laboratories, their characteristic patterns of investigation, their reward structures, and the relations between the two, so I have relied on more public sources [e.g., House Government Operations Committee 19711.)
Pharmaceutical research thus produces knowledge about the main effect a doctor might need to treat a patient. That is what the companies' advertising conununicates to physicians. If they looks carefully, they can find material on side effects and contraindications, but it is not pressed on them. In general, companies do not seek or force on the practicing physician information which would lessen the profitability of a drug they believe has good commercial possibilities.
Physicians, then, may not know that the drug has some effects it in fact has, or may not choose to tell the patient when they do know. When, for either reason, patients the drug is prescribed for don't know what it may do, they run two risks. They may have experiences which are quite pronounced, extremely unpleasant, and even dangerous, but not realize that they result from the medication. As a consequence, they may continue to take the drug that produces the unwanted side effect. For instance, certain commonly prescribed antihistamines occasionally produce urethral stricture; allergic patients who take large quantities may experience this but never report it to the allergist because it does not seem to be in his department. If the condition becomes severe they consult a urologist, who may discover they are taking large doses of antihistamine and cure the difficulty by recommending one that does not have this side effect. But not all physicians know of the connection, and failure of the patient to report or the physician to make the connection can lead to serious difficulty.
Patients may also experience symptoms which have an insidious and gradual onset, and never recognize that there is any change in their condition which requires explanation. This was apparently the experience of many women who took birth control pills (Seaman 1969). They suffered serious and continuing depression, but it appeared gradually and seemed nothing out of the ordinary, so that they did not realize anything had occurred which might be attributable to the hormone. This reaction is especially true of drugs taken for medical purposes; the mood changes they produce will be so gradual as not to be noticed or will be attributed to psychological difficulties, changes in social relationships, or other causes unrelated to the medication. Thus, the physician may treat the patient who begins to experience mood changes as neurotic, and the difficulty, when the user does become aware of it, will not only be undiagnosed but misdiagnosed. This must have happened frequently among early users of oral contraceptives, especially unmarried women, whom physicians often consider especially prone to neurotic symptoms (Seaman 1969).
In either case, the drug experience is amplified and the chance of serious pathology increases because doctors have insufficient knowledge of the drug's effects to warn patients, or because they choose not to warn them. Patients, not knowing what is likely to happen, cannot recognize the event when it occurs and respond adequately themselves or present their problem to an expert who can provide an adequate response.
As we have seen, knowledge accumulates in illicit drug-using groups when users are in touch with one another and communicate the results of their personal research to one another freely. Though the medical and scientific professions are organized in a way that ought to promote full communication of adverse drug reactions to practicing physicians, an important study shows that that communication can be impeded (Koch-Weser et al. 1969). Hospital physicians were asked to report all adverse drug reactions, and, simultaneously, clinical pharmacologists made independent checks on the same hospitalized patients. From two-thirds to three-quarters of the adverse reactions to prescribed drugs verified by the pharmacologists were not reported by the physicians. Physicians tended to report those adverse reactions in which morbidity and danger were high, and in which the connection between the drug and the reaction was already well known. This means that the system works poorly to accumulate new information, although it is relatively efficient in reconfirming what is already known. Add to this the probability that patients are probably less likely than illicit drug users to compare experiences on a large scale. There is then a substantial risk that adverse information will never be accumulated so that it can be passed on to the drug's ultimate users for them to use in interpreting such events occurring subsequent to drug use.
Many of the user's difficulties in interpreting his experience will result from the stage of development of knowledge about the drug. I have argued elsewhere that adverse reactions to illicitly used drugs decline as their use increases and a fund of knowledge grows among communicating users, allowing them to use that accumulated wisdom to regulate dosage and deal with adverse effects (Becker 1967b).
A similar natural history may occur with the use of drugs in medical practice. Doctors seek drugs which will make a decisive and noticeable improvement in a patient's condition. Pharmaceutical companies and researchers attempt to produce such drugs. In the effort to produce a noticeable improvement, company recommendations, insufficient research, and physician inclinations combine to produce a tendency to prescribe dosages larger than required for the desired medical effect, large enough to produce serious side effects. Because the research done prior to use on patients has not looked thoroughly into possible side effects, no one connects these occurrences with the new medication. Where the drug is potentially profitable, as in the case of antibiotics, adrenocortical steroids, or oral contraceptives, its use will be heavily promoted and widely publicized, so that physicians will feel pressure both from patients and the example of their more innovative peers to begin prescribing the new drug. Massive use, combined with a tendency to overdose, will produce enough adverse reactions that someone will eventually investigate and establish the connection. More such reactions will occur before the information filters through the barriers already discussed, but eventually conventional dosages will be lowered and the incidence of adverse reactions will decline. When they occur, furthermore, they will be recognized and treated more effectively. Eventually, presumably, the number of adverse reactions will reach a minimum based on the number of physicians who are either ignorant of their character or who do not communicate their knowledge to patients so that the reactions can be recognized, reported, and treated.
The introduction of oral contraceptives appears to embody this natural history. When they were first introduced, both the manufacturers and prescribing physicians were determined to use sufficicntly large doses so that they would not have to face the wrath of a pregnant woman who had been assured that that could not happen. The large doses produced serious side effects in a variety of organ systems, as well as severe psychological depressions. As knowledge of these effects became more widespread, many physicians (and others) did not wish to publicize them, since women who knew of them might refuse to take the pills. Eventually, doctors discovered that one-tenth the conventional dose was sufficient to produce effective contraception, with many fewer adverse reactions. With both physicians and users alerted by massive publicity, adverse reactions were more quickly reported and dealt with.
To what degree does the process I described occur because the investigation and production of medically prescribed drugs is carried on by profit-making corporations in a capitalist economy? Obviously, those elements of the process which reflect marketing strategies designed to maximize profits--focusing research on products likely to produce high sales at low costs and a relative neglect of potential side effects--would not occur in a noncapitalist economy. On the other hand, most of the other elements, reflecting as they do the interests of an organized medical profession as distinct from the interests of patients, would presumably occur in any developed society which contains such a group. The desire of physicians to achieve discernible results and to maintain control over patients would probably continue to influence the dissemination of knowledge from researchers to physicians to patients and, consequently, the kinds of experiences medical patients have as a result of using prescribed drugs.
Carlos Castaneda's not exactly trustworthy, but nevertheless informative, account (1968) of his instruction in the use of psychedelic substances by Don Juan is the only one I know of the delegation of control to a religious, rather than a medical, agent. The relationship between the two, and its effect on Castaneda's drug experiences, appears similar to the medical model. Don Juan often gave Castaneda insufficient information with which to interpret his experiences and avoid unpleasant experiences, because he felt Castaneda's inexperience (for which read "lack of professional training") would make it impossible for him to understand, because he wished to retain control over his student's progress, and because he wanted his pedagogy to produce the result he sought, even though the experience might be unpleasant or frightening for Castaneda in the short run and might ultimately result in failure. The disparity between teacher and student goals parallels the disparity between physician and patient interests and goals, and some of the resulting experiences of the user who has delegated control appear similar.
Control by External Agents
People sometimes find themselves required to ingest drugs involuntarily, the whole process under the control of independent agents who administer the drugs for their own purposes. The external agent's purposes sometimes conflict directly with those of the user, as when people find themselves the victim of chemical warfare (Hersh 1968) in the form of a poison-gas attack or a contaminated water supply. In other cases, external agents administer the drug because they believe it is in the best interest of the community to do so, as when people with tuberculosis or leprosy are medicated to prevent them from infecting others (Roth 1963). In such cases (and in such similar instances as the forced medication of mental hospital inmates and the administration of amphetamines to allegedly hyperkinetic schoolchildren) those administering the drug frequently insist, and believe, that the medication serves the ultimate interest of those who take it as well, however much they may wish to avoid it. In both chemical warfare and forced medication, the characteristic features of a serious disagreement about the legitimacy of the drug's administration and the consequent necessity of coercion to effect that administration appear. The crucial feature of the social structure in which the drugs are used, then, consists of an imbalance in power between those administering the drug and those to whom it is administered such that drug ingestion is forced on unwilling users.
Those administering the drug usually have goals quite divorced from anything the user might desire. Although physicians in ordinary medical practice have goals somewhat divergent from those of their patients, they must nevertheless take realistic account of the possibility that patients will cease coming to them unless the treatment proves satisfactory. When those administering the drug have sufficient control that users cannot escape, they can safely ignore the target's interests altogether,and their actions can be designed solely to serve their own interests, personal or (more likely) organizational.
The emphasis on the interests of those administering the drug shows up in the calculation of dosage. In contrast to the careful self-regulation characteristic of user-controlled drugs, and the attempt to prescribe a dose that will produce a result satisfactory to the user for whom one is acting as agent characteristic of agent control, external agents usually look for a maximum dose, one that will not fail to produce the result they seek. In the case of chemical warfare, they seek to kill or incapacitate those to whom the drug is administered, so they look for dosages in the range of the LD50 (the dose at which fifty percent of those dosed will die). In the case of mass administrations of tranquilizers in mental hospitals, they look for a dose which will allow patients to continue to take care of themselves but render them incapable of violence and totally suppress psychotic symptoms which interfere with hospital routine. In general, dosagcs are higher than in medically prescribed or self-regulated use, because they are meant to kill, disable, or control the target population, rather than cure their diseases or give them pleasure.
Since goals arc set unilaterally, those administering the drug must use coercive measures to insure that the desired dose reaches its target. As the divergence in goals between the two parties increases, the difficulty of administration increases proportionally. Physicians often worry that patients will suspect that their prescription is not good for them and thus not take their medicine. Where the divergence is relatively great and obvious, as in tuberculosis and mental hospitals, hospital personnel usually supervise patients' ingestion of medication very closely; even so, inmates often discover ingenious ways of evading forced medication.
In chemical warfare, where the parties'interests are diametrically opposed, the problem of an "effective delivery system" becomes extremely important, thus highlighting the degree to which other forms of drug ingcstion rely on users' voluntary cooperation. Chemical warfare agencies concern themselves with foolproof means of dosing entire populations, and so work on such devices as aerosols, which guarantee ingestion by saturating the air everyone must breathe, or methods of contaminating urban water supplies. In their zeal to dose all members of the target population, they create for themselves a problem which does not bother those who administer drugs in a more selective way that requires user cooperation. A homely example is the policeman who, attempting to subdue a political demonstrator with a pepper spray, neglects to allow for the wind blowing toward him and gets a faceful of his own medicine.
Those who administer drugs to involuntary users are either indifferent about providing those who get the drug with any knowledge about it or actively attempt to prevent them from getting that knowledge. Hospital personnel seldom inform inmates receiving forced medication about main or side effects or how they can best be interpreted. They may'suggest that "this pill will make you feel better" or that "the doctor thinks this will make you feel better" or that "the doctor thinks this will help your condition," but seldom give more detailed information. The difficulties occasioned by lack of knowledge already discussed can thus arise, though they may be counteracted by the development of a user's culture among people confined in total institutions and subject to the same drug regimen.
Where destruction or incapacitation of the target population is the aim, those who administer the drug may wish to prevent any knowledge that the drug is being administered, or of its effects, from reaching those who ingest it. In this way, they hope to prevent the taking of countermeasures and, by preventing the use of available knowledge to reach an understanding of what is happening, create, in addition to the drug's specific physiological effects, panic at the onslaught of the unknown. It was just this phenomenon that both Army chemical warriors and those of the psychedelic left hoped to exploit in the 1960s by putting LSD into urban water supplies. Not only, they hoped, would the drug interfere with people's normal functioning by causing them to misperceive and hallucinate; in addition, people would not even know that they had been given a drug which was causing these difficulties and so would be frightened as well. (As it turns out, Chicago's Mayor Daley need not have worried about Yippies putting LSD into the Chicago water supply during the 1968 Democratic Convention. As Army Chemical and Biological Warfare investigators had already discovered, LSD breaks down rapidly in the presence of chlorine, and the Chicago water supply routinely contained enough chlorine that one can easily taste it. This defect in LSD as a chemical warfare agent led the Army to an attempt to produce a water-soluble version of THC [tetrahydracannabinol, one of the active agents in marijuana], which otherwise is most easily ingested in smoke.)
If drug experiences somehow reflect or are related to social settings, we must specify the settings in which drugs are taken and the specific effect of those settings on the experiences of participants in them. This analysis suggests that it is useful to look at the role of power and knowledge in those settings, knowledge of how to take the drugs and what to expect when one does, and power over distribution of the drug, knowledge about it, and over the decision to take or not take it. These vary greatly, depending on the character of the organization within which the drugs are used. In illicit drug use, the effects of the drug experience depend on the social links and cultural understandings that grow up among those who use the drug. In the use of medically prescribed drugs, the effects reflect the profit orientation of pharmaceutical manufacturers and the characteristic professional dominance exercised by physiclans. Where drug use is forced on people, the results reflect the unilateral exercise of power in the interest of the stronger party.
Naturally, these are pure types, and many situations in contemporary society are mixtures of them. Many people, for instance, originally begin taking a drug because a physician has prescribed it for them, but then continue to get supplies of it in illicit or semi-licit ways; their use probably contains features of both user control and control by the user's agent. Folk medicine probably consists of a similar mixture, since folk curers may not have professional interests that diverge from those of their patients to the same degree the modern physicians do; then again, they may. Empirical cases won't fall neatly into one or another of these categories. Rather, the pure categories I have discussed show most clearly how knowledge and power can influence the experience of a drug user. Much more needs to be known about the pure types I have described (it may turn out that my analyses are one-sided and incomplete), as well as about the numerous marginal types that exist.
As I wrote this, I became conscious of the ambiguity of the very idea of a "drug." Much of what I have said about use enforced by a powerful external agent could be applied without much change to our daily ingestion of the pollutants in air, water, and food. Is smog a drug? Why not? Many people consider the fluoridation of city water supplies an instance of chemical warfare against them, sometimes going so far as to attribute the action to a foreign enemy. Are fluorides drugs? Clearly, we label as "drugs" a somewhat arbitrary selection of the materials we routinely ingest. It might be useful to look at the entire commonsense classification of ingested substances to see how we decide to call some things "foods," others "drugs," still others "pollutants" and whatever other categories people use. We could then ask what the consequences of such differential labeling are. We take different kinds of regulatory actions with respect to foods, drugs, and pollutants. What are the differences? How do they affect the distribution of knowledge and power with respect to ingestion of these materials and, therefore, the distribution of various kinds of experiences among those ingesting them? By extending the analysis I have begun here with respect to drugs, we might gain greater understanding of such diverse phenomena as smog poisoning, malnutrition, and indigestion.
The analysis might similarly be extended, in another direction, from consideration of chemically induced physical and psychological experiences to those produced by diseases of various kinds. We can investigate, for example, the way information about the effects of diseases is generated. What kind of research? Done by whom? With what ends in mind? And how it is communicated. In what social channels? With what barriers to overcome? We can then see how the resultant distribution of knowledge affects people's responses to their symptoms.
Beyond that, and of more general import, we can investigate the sociology of normal physiological functioning. Consider that medical symptoms exhibit themselves as departures from normal function: breath that is "shorter" than normal, appetite that is "less" than normal, pain that is beyond normal expectation, bowel movements that are "unusual," and so on. What is the folk wisdom with respect to "normal functioning"? How is it taught and learned? How does it vary from group to group?
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